The body is built for intercourse and women should be able to handle it just fine. Still, why do so many women suffer from painful sex (dyspareunia), and are shy to speak up about it?
- Is suffering an inherent trait in women?
- Is the partner at fault?
- Is society to be blamed? Or culture? Religion?
Excluding a justifiable medical reason, the causes are deeply rooted in the woman’s psyche and include
- The sense of “I do not deserve any better…”
- The feeling of “I am the only one who is struggling so I may as well just keep quiet…”
- The inherent tendency of women to be pleasers, at their own expense;
- The fear of “Partner will leave me if I speak up… I do not want to be alone…”
- A statement like “In my culture women submit, quietly; speaking up will have negative repercussions…”
- Some religions where women are expected to be subservient to the husband’s sexual wants;
- The woman’s inability to say NO, to speak up her preferences!
Additionally, the thrusting (penis’ motion) during intercourse is a rapid, powerful physical action inside the vagina, easily felt throughout the woman’s pelvis and body. While normal for the woman to experience it without much thought in the matter, it may turn painful or even traumatic.
Such suffering will typically lead to a deepening sense of victimization, resentment, avoidance, friction in the relations, and often to developing vaginismus. After all, it is against human nature to be made helpless, hopeless, forced upon.
Important: the vagina is a hostess to the penis! Its owner – the woman – determines if and when to invite the penis in, how long it can stay in, and when it is time to leave. Have you ever thought of that in such terms?
We encourage all women to speak up, to educate themselves, to have a dialogue with their partner, to seek professional help so as to put a stop to their unnecessary pain and suffering.
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Table of Contents
- What is Dyspareunia
- What is The Definition of Painful Sex (Dyspareunia)?
- What Are The Types of Painful sex (Dyspareunia)?
- What Are the Causes of Painful Sex (Dyspareunia)?
- Suffering From Painful Sex (Dyspareunia)
- Treatment for Painful Sex (Dyspareunia)
- How To Get Rid of Painful Sex (Dyspareunia)?
- Less Painful Sex Positions
- Painful Sex (Dyspareunia) During Pregnancy
- Painful Sex (Dyspareunia)After Childbirth
- Painful Sex (Dyspareunia) After Miscarriage, Abortion, Hysterectomy, D&C, Surgery
- Painful Sex (Dyspareunia) & Yeast Infection, UTI
- First Time Painful Sex
- Painful Sex (Dyspareunia) & Endometriosis
- Painful Sex (Dyspareunia) During Ovulation
- Painful Sex (Dyspareunia) & Period
- Painful Sex (Dyspareunia) & IUD
- Painful Sex (Dyspareunia) After Episiotomy
Painful sex (dyspareunia) is defined by dividing the presenting symptoms into three categories: onset, frequency, and location:
- Onset asks about the start of the problem: has it been there since the first time intercourse was attempted (primary, or lifelong dyspareunia), or did it start after a period of having normal intercourse (secondary, or acquired dyspareunia)?
- Frequency examines whether the problem occurs with all partners and in all penetrative situations (complete, or generalized dyspareunia), or only at times, with certain partners, in certain positions, or because of certain circumstances (situational dyspareunia).
- Location describes whether the pain is upon initial penetration at the vaginal opening (insertional, or superficial dyspareunia) or during thrusting and full penetration (deep dyspareunia).
Putting it all together, since painful sex may present itself in different combinations, a thorough assessment is imperative to identify the particular type of dyspareunia the woman has. Typical variations may include:
- Primary, situational, deep: thrusting always hurts while the woman is in a specific intercourse position (missionary, or woman-on-top, or side-by-side, etc.); other positions are okay;
- Secondary, situational, insertional: experiences pain with a current partner upon the beginning of penetration, but it goes away as soon as the man’s penis is halfway in; never happened with prior partners; pain is not as bad during the menstrual cycle;
- Primary, complete, superficial, and deep: the woman has always experienced pain, with all partners, in all positions, throughout the sexual act;
- Secondary, complete, superficial: initial penetration has been painful since a disruptive life event (surgery, childbirth, injury, etc.) regardless of sexual position, use of lubrication, choice of partner.
Unfortunately, many women are putting up with painful intercourse, depriving themselves of healthy intimacy, which should be the cornerstone of any relationship. Women rarely seek medical assistance to discuss sexual difficulties, a fact that makes it impossible to assess the prevalence of dyspareunia (and vaginismus, for that matter).
The two main reasons behind this reluctance are women’s tendency to accept pain as an inevitable part of intercourse, and their worry that the clinician will ridicule them or dismiss their complaints as “being crazy.”
The sad truth is that not all clinicians are attuned to this condition’s nature or presence, nor are they comfortable discussing such intimate matters. Although there have been gains in this direction in recent years, taking a thorough, detailed sexual history at the doctor’s visit is still not the standard of care.
- Medical causes, such as vaginal infections, sexually transmitted infections, skin conditions, hormonal problems, endometriosis, conditions of the intestines or genitals or urinary system;
- Physical causes, such as vaginal abrasions, scars, nerve damage, complications from vaginal delivery, cancer treatment/radiation, size incompatibility;
- Functional causes, such as genital irritation due to excessive hygiene or sensitivity to cleansing agents, poor hygiene, friction irritation due to sports such as cycling or horseback riding, insufficient vaginal lubrication, certain medications that cause excessive dryness;
- Psychophysical causes, such as vaginismus, postpartum crisis, interpersonal difficulties, forced sexual encounters.
- Breast cancer
- Female (gynecologic) Cancer
- Sjogren’s Syndrome
Learn about our proprietary treatment for sexual pain, the DiRoss Methodologysm
Naturally, when intercourse is painful, the woman will want to avoid the act. Furthermore, she may also decline outercourse (non-penetrative sex, such as oral or manual) because she does not want to be reminded of the pain, disappointing the partner, or worried that he will sneak into her vagina. Another major avoidance is being totally shut down sexually – a common coping mechanism of women that does not take much to develop.
From a psychophysical point of view, let us be reminded that intercourse is about the penis entering the woman’s body — being the “do-er” to her being ‘done to’ — and, therefore, it has to be invited and welcomed into her vagina when her body and mind are in sexual balance.
Painful sex (dyspareunia) can be a source of great conflict and anxiety to the woman who suffers from it, causing marked distress and interpersonal difficulties. Although intercourse is possible, the accompanying pain has been associated with a more negative attitude toward sexuality, more sexual function impairment, and lower levels of sexual adjustment. By putting up with painful intercourse, women deprive themselves of the healthy intimacy that is the cornerstone of a happy relationship. This opens the door to further psychosomatic breakdowns.
Painful Sex (Dyspareunia) & Bleeding
Painful Sex and bleeding is a common occurrence.
When you bleed during sex, however, it does not always mean there is a medical issue. There may be different reasons for bleeding during sex, including irritation, vaginismus, and first-time intercourse.
See our post about painful sex and bleeding for more information.
A thorough assessment is imperative to identify the woman’s particular type of dyspareunia and to offer the appropriate intervention.
The clinician who takes the time to obtain a complete and careful medical, emotional, and sexual evaluation can help resolve most cases of painful intercourse (dyspareunia).
For our treatment program:
- The partner doesn’t need to come along for the sessions unless otherwise instructed;
- An initial evaluation will be conducted and a treatment plan will be mapped out;
- The treatment itself is about 2-7 sessions depending on the cause, and rarely more than 10 sessions;
- Read our Insurance page for instructions on how to get reimbursed for the treatment.
It is not possible to make a comprehensive list of how to solve painful sex because the causes vary and each woman will need her own solution. However, some commonalities exist:
- Recognize there is a problem;
- Stop having intercourse – why suffer????? But do enjoy other sexual activities that are not penetrative, such as oral, manual, etc.;
- Speak up about it with your partner, do not keep it a secret!
- Seek medical advice: see your clinician, explain the situation, undergo an examination;
- Search for more/different information if still not sorted out.
A woman’s body can continue to have pain-free intercourse provided she takes care of her vaginal needs during her life cycles.
Choosing sexual positions is an inevitable component of sexual intimacy:
- Most partners will vary positions so as to reduce boredom;
- Men will typically opt for more of a variety than women;
- The position of choice will vary due to physical considerations, painful intercourse, injury, pregnancy, post-childbirth, surgery, the comfort of bedding (or wherever the action takes place), age, or Peyronie’s disease;
- Religious/cultural considerations are a factor.
Depending on the cause of YOUR painful sex (dyspareunia), opt for positions that are comfortable, stress-free, and pain-free so you can enjoy being intimate without worrying or suffering. Your partner will need to respect your choice and preference and should not pressure you into a painful position for the sake of their own wants and likes.
Pregnancy is typically a happy time for the woman, not only emotionally but also physically under the influence of increased estrogen in her body and, barring medical issues or restrictions, she will continue to be sexually active.
Painful sex in early pregnancy or in second trimester are not typical unless the woman has a prior history of such.
But, as her abdomen swells into the third trimester and her body begins to prepare for childbirth, she could experience logistical issues, such as position, lack of interest, fatigue, and painful sex. If that is you, do not force yourself – engage sexually if interested, and however comfortable while enjoying this special journey of almost-becoming-a-mom.
The Fourth Trimester is defined as the time between delivery and the 12th week after giving birth during which the woman’s uterus shrinks, vaginal bleeding ceases, tears or episiotomy heal, energy is restored, emotional state stabilizes, family dynamics are realigned as the woman adjusts to her new life. Of note, postpartum recognition is found in most cultures and religions, albeit with different practices.
Barring medical instructions to the contrary, a woman can become sexually active at approximately the sixth week postpartum when her body has restored itself, yet many women are still hesitant or don’t feel ‘ready’ to resume sexual intimacy and may struggle with postpartum painful sex (dyspareunia) because of
- Fatigue, sleeplessness;
- Anxiety, especially first-time mothers who are more vulnerable to this new experience of motherhood;
- Painful healing episiotomy, C-section scar, hemorrhoids;
- A dry vagina, Insufficient lubrication;
- Embarrassment about leaking urine;
- Fears: can the vagina handle the penis’ thrusting? Will it tear the episiotomy?
- Vaginismus considerations: did having a baby vaginally cure it? Can the penis fit? Why am I afraid to even try penetrations?
- Not feeling ‘sexy’ with new body, leaking breasts, recovering vagina…
- Overwhelmed with the new life and responsibilities;
- Relationship breakdowns;
- Is the partner/husband putting forth demands, with the typical, “You love the baby more than me… You do not pay attention to me as much as to baby”?
- Postpartum depression. Note: history of anxiety or depression increases the likelihood of postpartum depression;
- Life too busy – work, multiple kids, etc. – cannot find a time to shut down her racing mind and dive into the physical nice of sexual intimacy.
The female sexual template is largely controlled by her mind, with the clitoris being her sexual organ of arousal. It is very easy for a woman to ‘kill’ sexual interest with the slightest worry or negative thought, and to develop postpartum dyspareunia.
Healthy restoration of sexual intimacy postpartum is imperative; resources include your maternity provider, a mental health clinician, a sex therapist, a pelvic floor physical therapist.
Take your time to explore and experiment. There are solutions available to postpartum dyspareunia and you need not suffer, feel that you are alone, or that there is no hope. The value of sexual intimacy goes a long way in promoting relationship and emotional health.
Your doctor will advise when your body is ready to resume penetrative sexual intimacy following a miscarriage, an abortion, a hysterectomy, or any other surgical procedure.
Post surgical painful sex (dyspareunia) may be caused by scar sensitivity, chafing and bleeding, physical restrictions, narrowing, tenderness, and a different feeling if there were surgical alterations.
Naturally, women anticipate these possible reactions and will be nervous to actually subject their genitals to penile penetration, which may easily translate to their vagina ‘stiffening up’ and resulting in a psychosomatic provocation of painful sex (dyspareunia).
Suggestion: if you cannot overcome the above on your own, seek treatment from your clinician or a pelvic floor physical therapist who will guide through the process.
Every woman will experience a vaginal yeast infection at least once in her lifetime because of chafing irritation or having taken antibiotics for an infection anywhere in the body. And most women will also have experienced Urinary Tract Infection (UTI) once or more.
The infection may cause unpleasant sensations, such as itching, burning, pressure, and an unusual discharge, while the antibiotics will have a drying effect on the vagina. Both combined and you have a good cause for painful sex (dyspareunia).
And then there is the psychosomatic pattern: the woman was on antibiotics > she got a yeast infection > she was given medication/s for it > the infection persisted > she was also given topical medications > more burning of genital lips/vagina > more dryness and irritation > penetration becomes uncomfortable > anxiety set in > penetration becomes impossible >> the birth of painful sex (dyspareunia) and even secondary vaginismus.
What to do? While being treated, refrain from sexual activity and let your vagina heal; once cleared, use added lubrication for comfort and elasticity to resume sexual activity. You may also want to speak with your clinician about taking probiotics for further restoration of your urogenital system.
Not all women experience painful sex (dyspareunia) the first time they have vaginal sex, but some do for the following reason/s:
- A hymen that broke;
- A dry vagina;
- The act lasted longer than comfortable for you;
- A larger penis (not a common cause);
- Anxiety, worries, or fear about penis penetration;
- Primary vaginismus
Sort it out and hopefully your next time will be fine. If not, seek medical advice.
Endometriosis is a condition where the tissue lining the uterus grows in adjacent areas, such as the ovaries, Fallopian tubes, pelvis, and around the intestines. The typical symptoms are pelvic pain, painful sex (dyspareunia), menstrual irregularities, and some will also experience infertility. Some women will have no symptoms.
Endometriosis does not prevent a woman from having vaginal intercourse provided she makes adjustments for comfort:
- Choose a sexual position that does not cause pressure pain when his penis is thrusting against your uterus;
- Modify his thrusting depth and velocity against the uterus;
- Add lubrication as needed to make the act comfortable;
- Place a pillow under your buttocks when in missionary position to functionally ‘lengthen’ the vagina (it won’t lengthen structurally but the uterus will slide upward some);
- Pace out the frequency of sexual intercourse as you see fit;
- If you had endometrial surgery, resume sexual intimacy when permitted;
- Mind your anxiety, if present, and seek medical advice;
- Unable or lost the ability to have vaginal penetration? Explore vaginismus.
The ovaries take turns ovulating, never both at the same time: one month on one side, the next month on the other side.
Ovulation takes approximately 12-24 hours.
Ovulation may cause some women pain and discomfort, lasting a few minutes to a few hours.
If you find that having sexual intercourse during that time is painful, just refrain. If the pain persists beyond that timeframe, speak with your clinician.
If you suffer from Premenstrual Syndrome (PMS), including tender breasts, fatigue, irritability, and depression, and find it undesired or uncomfortable to engage sexually, then don’t. The goal is not to bring on painful sex (dyspareunia) patterns.
The decision of whether to have intercourse during menstruation is a personal one: some do, some don’t, others do sometimes. Those who don’t will typically refrain because it may be quite a messy deal, or because it is not aesthetically appealing to them, or because of cultural/religious restrictions.
Having vaginal sex during the period may be painful to some women because of cramps, vaginal chafing by the acidity of the menstrual blood, low back discomfort, and such. If this is the case, refrain from sex during that time. It does not take much to start a psychosomatic sexual pain pattern in the genitals, something you would like to avoid at all cost!
the IUD – Intrauterine Device – is a little apparatus that is inserted into the uterus, as its name implies. Whether a hormone-releasing IUD or a copper IUD, they are both safely nestled inside the uterus and are completely unaffected by vaginal action, may it be sexual, tampon use, gyno exam, etc.
Your partner may feel the IUD’s string during intercourse, and you can always feel it when checking for its presence but putting your finger in the vagina.
However, painful sex (dyspareunia) may occur if the IUD was improperly placed or if it got displaced. Seek medical advice if that happens, and you cannot feel the string, the string feels shorter or longer, you experience cramping, stabbing sensation, and discomfort with or without bleeding.
A healed episiotomy should not cause any painful sex (dyspareunia) once healed, and the woman gets the go-ahead to resume vaginal sexual activities.
In some women there may be complications, including
- The episiotomy was sutured tight, restricting vaginal access;
- The episiotomy did not heal and had to be revised, leading to tight healing;
- The episiotomy resulted in keloids (painful scarring);
- Other medical/surgical complications;
Speak with your clinician about solutions so you can resume pain-free sexual activities.
Ditza Katz, PT, Ph.D., is the founder of Women’s Therapy Center, a practice specializing in urogynecology rehabilitation, treatment of female sexual dysfunction, including vaginismus, breast & female cancer rehabilitation, and management of somatic disorders.
Dr. Katz holds an undergraduate degree in Physical Therapy, a Master’s degree in Pastoral Psychology & Counseling, a doctorate in Clinical Sexology, and clinical training in manual therapy and urogynecology.
Ross Lynn Tabisel, LCSW, Ph.D., is Co-Director of the Women’s Therapy Center and a Diplomat with the American Board of Sexology.
She holds a Master’s degree in Social Work from Adelphi University, a Post – Graduate Certificate in Psychotherapy and Psychoanalysis from the Institute for the Study of Psychotherapy in New York, a doctorate in Clinical Sexology, and a Certificate Training in the area of Sexual Abuse.